Download The Challenge of Respiratory Disorders for the NHS

Dr Emma Denneny & Dr Sarah Clarke
Respiratory SpRs
Princess Alexandra Hospital
1. COPD & Asthma – the scale of the challenge
- Prevalence globally to nationally
2. COPD & Asthma – diagnosis & risk factors
3. Our day-to-day service delivery challenges
4. The Future
- Precision Medicine
- Case for a ‘Chronic Airways Disease Spectrum’?
- Challenge of delivering a tailored approach
COPD (Chronic Obstructive Pulmonary Disease)
Progressive airflow limitation that is not fully reversible
Onset mainly in mid-life
Preventable – usually associated with smoking
Asthma
Reversible airflow limitation
Onset mainly in childhood
Variability in symptoms
For patients with FEV1/FVC <0.70;
Severity
Gold 1-Mild
FEV1 % predicted
≥80
Gold 2-Moderate
50-79
Gold 3-Severe
30-49
Gold 4-Very Severe
<30
WORLD - 2012
UK – 2005 & 2010
COPD
• 835,000 people with COPD in the UK
• Fifth leading cause of death in the UK
• £800 million per year on managing COPD
Asthma
• 6 million people in UK receiving treatment for asthma
• 8 million people have an asthma diagnosis (GP record)
• 1200 deaths per year from asthma (245 <65 years old)
• £1 billion per year on managing asthma
Both conditions have a high rate of emergency hospital admissions
Genetic Factors
Environmental
Exposures
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Comorbid
Disease
Tobacco smoking
Occupational dusts & fumes
Air pollutants
Ageing
Infections
Genetics: α-1 antitrypsin deficiency & predictors of lung
function
• Comorbid disease
• A complex metabolic syndrome associated with underlying
illness
• Loss of muscle mass with or without loss of fat mass
• Impairs physical performance
• Increases mortality risk
• COPD specific cachexia drivers:
• Emphysema
• Decreased muscle oxidative phenotype
• Exacerbations
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Calories – appetite stimulants
Dietary protein – pharmacological intervention
Exercise
Cognitive Behavioural Therapy
• Pulmonary Rehabilitation
Individual & group sessions
Exercises
Breathing techniques
• Home oxygen
• Chest physiotherapy
• Smoking cessation
• GP services / community COPD teams – inhaler technique
• Charity support groups
Respiratory Team
4 consultants, 2 specialist respiratory nurses, 3 SpRs, 5 SHOs & 3
secretaries/administrators
• Given the high prevalence, a great proportion of COPD/asthma
patients are managed by GPs in the community.
• In clinic we are involved in diagnosis, commencing treatment,
reviewing complex patients & considering candidates for new
therapies/surgical interventions.
• On the ward we frequently manage patients with exacerbations
of COPD/asthma.
• Amongst our frequent attenders, many have co-existing
psychosocial issues that we have to manage in addition.
• Anxiety surrounding the symptom of breathlessness
• Young asthma patients & compliance
• Side effects of treatment
• For our end-stage COPD patients, considering ceiling of care &
palliative input
• Respiratory failure & non-invasive ventilation
• Hospital bed pressures & safe discharges
• Continuity of care & services in the community
• Are the historical diagnostic labels of asthma and COPD an
outdated approach to understanding an individual's condition?
• Are the terms too broad?
• Should we use a more personalised approach to management
that identifies 'treatable traits' in each patient?
• New technologies
• Previously we relied on analysis of symptoms and signs e.g.
lung function and airway hyper-responsiveness
• But now we have detailed imaging techniques available and we
can access information regarding complex biological traits
• cellular and molecular markers taken from blood samples, sputum and
exhaled air and microbiome anaylsis.
"We propose a label-free precision medicine approach based on
treatable traits that categorise the clinical and biological complexity
of airway disease. The approach we are suggesting would radicalise
healthcare and have significant implications for the organisation of
a healthcare system. By recognising the clinical and biological
complexity of a disease, we can use causal mechanistic disease
pathways to adopt a more precise approach, which is hopefully
more effective at managing patients with these conditions.”
Professor Alvar Agusti
European Respiratory Journal
February 2016
• Challenge of meeting the demands of an ageing population
• Challenge of tailoring care to the individual patient
• Challenge within field of research to identify disease targets
and categorise disease appropriately
• British Lung Foundation – Statistics
• Office for National Statistics - Deaths Registered in England and Wales in
2010, by Cause
• Mannino & Buist (2007) Global Burden of COPD: risk factors, prevalence &
future trends. The Lancet 370; 765-773
• Hawkins et al. (2013) Heart Failure & COPD: the challenges facing
physicians & health services. Eur Heart Journal 34; 2795-2803
• Augusti et al. (2015) Biomarkers, the control panel & personalised COPD
medicine. Respirology 21; 1
• Schols et al. (2014) Nutritional Assessment & Therapy in COPD. European
Journal Resp Med 44; 1504-20